Low Potassium Levels Research Articles

Case Report: Periodic Hypokalemic Paralysis

Hypokalemic periodic paralysis is characterized by muscle weakness or flaccid paralysis followed by low potassium levels (less than 3.5 mmol/L) during the attack. Proper initial management and patient education are mandatory for health workers to manage this case. This study was a descriptive study with a case report approach. This case report includes patients over 18 years receiving health care at the Negara General Hospital and having accessible medical record data. Data collection was carried out consecutively. A case from a 22-year-old man with complaints of weakness in both legs. The examination found lower extremity motor strength 2/2, normal physiological reflexes without pathological reflexes, and a laboratory potassium level of 2.5 mmol/L laboratory results. The patient was then given hypokalemia treatment with KCl intravenously. The patient, in this case, had no clinical condition contraindicated to give potassium. Within 24 hours after potassium administration, the patient showed a significant improvement. Hence, our therapy, in this case, was in line with the theory with a good clinical outcome. Symptomatic therapy in hypokalemic periodic paralysis provides a good clinical outcome. There were no complications or clinical emergencies during treatment.

Effect of Iron and Silicon on Growth and Yield of Sorghum (Sorghum bicolor L.)

The present study highlights the effect of Iron and Silicon on growth and yield of Sorghum (Sorghum bicolor L.). Si occurs primarily in soil solution as monosilicic acid (H4SiO4) at concentrations ranging from 0.1 to 0.6 mm and is taken up by plants in this form. Silicon can mitigate the negative effects of abiotic stresses such as high temperature, freezing, drought, lodging, radiation, irradiation, and UV, as well as chemical stresses such as salt, nutrient imbalance, and metal toxicity. A field experiment was conducted during Zaid season 2022 at experimental field of Crop Research Farm, Department of Agronomy, Naini Agricultural Institute, Sam Higginbottom University of Agriculture, Technology and Sciences, Prayagraj, Uttar Pradesh, India. The soil at the test site had a sandy loam texture, a pH of 7.3 that was almost neutral, and low levels of available potassium (215.4 kg/ha), nitrogen (230 kg/ha), phosphorus (13.60 kg/ha), and organic carbon (0.48%). The treatments consist of foliar spray of iron (0.5, 1.0, 1.5 %) at 35, 45 DAS and Foliar spray of Silicon (0.5, 1.0, 1.5 ml/L) at 50 DAS along with control (RDF: 80:40:40 NPK Kg/ha). The experiment was layout in Randomized Block Design with ten treatments each replicated thrice. Significantly higher plant height (205.66 cm), maximum plant dry weight (133.2 g) and the yield attributes namely test weight (25.82 g), grains/earhead (2368.33), grain yield (2850.00 Kg/ha), stover yield (4004.67 Kg/ha), maximum gross return (84645.00 INR/ha), net return (52313.00 INR/ha) and benefit cost ratio (1.61) were obtained in the treatment 9 with the application of 1.50% Iron along with 1.50ml/L Si.

Serum Potassium and Risk of Death or Kidney Replacement Therapy in Older People With CKD Stages 4-5: Eight-Year Follow-up

Hypokalemia may accelerate kidney function decline. Both hypo- and hyperkalemia can cause sudden cardiac death. However, little is known about the relationship between serum potassium and death or the occurrence of kidney failure requiring replacement therapy (KRT). We investigated this relationship in older people with chronic kidney disease (CKD) stage 4-5. Prospective observational cohort study. We followed 1,714 patients (≥65 years old) from the European Quality (EQUAL) study for 8 years from their first estimated glomerular filtration rate (eGFR)<20mL/min/1.73m2 measurement. Serum potassium was measured every 3 to 6 months and categorized as≤3.5,>3.5-≤4.0,>4.0-≤4.5,>4.5-≤5.0 (reference),>5.0-≤5.5, >5.5-≤6.0, and>6.0mmol/L. The combined outcome death before KRT or start of KRT. The association between categorical and continuous time-varying potassium and death or KRT start was examined using Cox proportional hazards and restricted cubic spline analyses, adjusted for age, sex, diabetes, cardiovascular disease, renin-angiotensin-aldosterone system (RAAS) inhibition, eGFR, and subjective global assessment (SGA). At baseline, 66% of participants were men, 42% had diabetes, 47% cardiovascular disease, and 54% used RAAS inhibitors. Their mean age was 76±7 (SD) years, mean eGFR was 17±5 (SD) mL/min/1.73m2, and mean SGA was 6.0±1.0 (SD). Over 8 years, 414 (24%) died before starting KRT, and 595 (35%) started KRT. Adjusted hazard ratios for death or KRT according to the potassium categories were 1.6 (95% CI, 1.1-2.3), 1.4 (95% CI, 1.1-1.7), 1.1 (95% CI, 1.0-1.4), 1 (reference), 1.1 (95% CI, 0.9-1.4), 1.8 (95% CI, 1.4-2.3), and 2.2 (95% CI, 1.5-3.3). Hazard ratios were lowest at a potassium of about 4.9mmol/L. Shorter intervals between potassium measurements would have allowed for more precise estimations. We observed a U-shaped relationship between serum potassium and death or KRT start among patients with incident CKD4-5, with a nadir risk at a potassium level of4.9mmol/L. These findings underscore thepotential importance of preventing both high and low potassium in patients with CKD 4-5. Abnormal potassium blood levels may increase the risk of death or kidney function decline, especially in older people with chronic kidney disease (CKD). We studied 1,714 patients aged≥65 years with advanced CKD from the European Quality (EQUAL) study and followed them for 8 years. We found that both low and high levels of potassium were associated with an increased risk of death or start of kidney replacement therapy, with the lowest risk observed at a potassium level of 4.9 mmol/L. In patients with CKD, the focus is often on preventing high blood potassium. However, this relatively high optimum potassium level stresses the potential importance of also preventing low potassium levels in older patients with advanced CKD.

Study of Socio-economic, Biochemical and Clinical Predictors of Alcohol Withdrawal and Delirium Tremens in Patients of Alcohol Dependence in Indian Population

Abstract Background: Alcohol withdrawal syndrome (AWS) is associated with morbidity and mortality. Assessment of factors affecting AWS will help in early diagnosis and initiation of appropriate treatment, hence improving the prognosis. Aim: The present study was conceived and planned to assess the socioeconomic, biochemical, and clinical predictors of alcohol withdrawal and delirium tremens with alcohol dependence patients in the Indian population. Study Design: Longitudinal study. Methodology: The study includes 100 patients admitted for alcohol withdrawal. Participants were assessed for detailed history, physical and mental state examination, CAGE scale (Cut down, Annoyed, Guilty, Eye-opener), AUDIT scale (Alcohol Use Disorders Identification Test), PAWSS scale (Prediction of Alcohol withdrawal severity Score), MINIPLUS (Mini-International Neuropsychiatric Interview) scale and CIWA scale (Clinical Institute withdrawal Assessment of Alcohol) scoring along-with biochemical and hematological investigations. Statistical analysis was done by using SPSS version 20. Results: Mean age of the patients observed was 33.91 years (19-70 years). A significant association between increase of mean corpuscular volume (MCV) and total bilirubin levels (P= 0.208); highly significant association between low platelet counts, low potassium levels, serum glutamic pyruvic transaminase (SGPT), serum glutamic oxaloacetic transaminase (SGOT), alkaline phosphatase (ALP) and the development of delirium tremens and severity of alcohol withdrawal was observed (P&lt;0.05). CAGE (P&lt;0.014), AUDIT (P&lt;0.001), and CIWA scores has significant association (P&lt;0.001) with development of delirium and PAWSS showed good prediction (P&lt;0.007) with patients having severe alcohol withdrawal. Conclusion: Our study recommends that socioeconomic and biochemical factors and predictors can be considered for early diagnosis of severity of alcohol withdrawal and delirium tremens.

Evaluating the American Urologic Association (AUA) dietary recommendations for kidney stone management using the National Health And Nutritional Examination Survey (NHANES).

The objective of this study is to evaluate the conventional dietary recommendations for stone prevention among patients in the National Health and Nutritional Examination Survey (NHANES) and compare dietary components and special diets between stone formers and non-stone formers. We analyzed the NHANES 2011-2018 dietary and kidney condition questionnaires, among 16,939 respondents who were included in this analysis. Dietary variables were selected based on the American Urological Association (AUA) guideline for Medical Management of Kidney Stones and from other studies on kidney stone prevention. Weighted multivariate logistic regression models were used to assess the relationship of dietary food components (categorized into quartiles) and dietary recommendations with kidney stone formation (yes vs no), adjusted for total caloric intake, comorbidities, age, race/ethnicity, and sex. The prevalence of kidney stones was 9.9%. Our results showed association of kidney stones with lower levels of potassium (p for trend = 0.047), which was strongest for < 2000mg (OR = 1.35; 95% CI 1.01-1.79). Higher vitamin C intake was inversely associated with stone formation (p for trend = 0.012), particularly at daily intake levels between 60 and 110mg (OR = 0.76; 95% CI 0.60-0.95) and above 110mcg (OR = 0.80; 95% CI 0.66-0.97). There were no associations between other dietary components and kidney stone formation. Higher levels of dietary vitamin C and potassium intake may be indicated for stone prevention and warrants further investigation.

Does Potassium Modify the Response of Zinnia (Zinnia elegans Jacq.) to Long-Term Salinity?

Salinity is one of the major abiotic stress factors hindering crop production, including ornamental flowering plants. The present study examined the response to salt stress of Zinnia elegans 'Lilliput' supplemented with basic (150 mg·dm-3) and enhanced (300 mg·dm-3) potassium doses. Stress was imposed by adding 0.96 and 1.98 g of NaCl per dm-3 of the substrate. The substrate's electrical conductivity was 1.1 and 2.3 dS·m-1 for lower potassium levels and 1.2 and 2.4 dS·m-1 for higher potassium levels. Salt stress caused a significant and dose-dependent reduction in leaf RWC, increased foliar Na and Cl concentrations, and reduced K. About 15% and 25% of cell membrane injury at lower and higher NaCl doses, respectively, were accompanied by only slight chlorophyll reduction. Salt stress-induced proline increase was accompanied by increased P5CS activity and decreased PDH activity. More than a 25% reduction in most growth parameters at EC 1.1-1.2 dS·m-1 but only a slight decrease in chlorophyll and a 25% reduction in the decorative value (number of flowers produced, flower diameter) only at EC 2.3-2.4 dS·m-1 were found. Salt stress-induced leaf area reduction was accompanied by increased cell wall lignification. An enhanced potassium dose caused a reduction in leaf Na and Cl concentrations and a slight increase in K. It was also effective in membrane injury reduction and proline accumulation. Increasing the dose of potassium did not improve growth and flowering parameters but affected the lignification of the leaf cell walls, which may have resulted in growth retardation. Zinnia elegans 'Lilliput' may be considered sensitive to long-term salt stress.

Cardiovascular and metabolic characters of KCNJ5 somatic mutations in primary aldosteronism.

Primary aldosteronism (PA) is the leading cause of curable endocrine hypertension, which is associated with a higher risk of cardiovascular and metabolic insults compared to essential hypertension. Aldosterone-producing adenoma (APA) is a major cause of PA, which can be treated with adrenalectomy. Somatic mutations are the main pathogenesis of aldosterone overproduction in APA, of which KCNJ5 somatic mutations are most common, especially in Asian countries. This article aimed to review the literature on the impacts of KCNJ5 somatic mutations on systemic organ damage. PubMed literature research using keywords combination, including "aldosterone-producing adenoma," "somatic mutations," "KCNJ5," "organ damage," "cardiovascular," "diastolic function," "metabolic syndrome," "autonomous cortisol secretion," etc. APA patients with KCNJ5 somatic mutations are generally younger, female, have higher aldosterone levels, lower potassium levels, larger tumor size, and higher hypertension cure rate after adrenalectomy. This review focuses on the cardiovascular and metabolic aspects of KCNJ5 somatic mutations in APA patients, including left ventricular remodeling and diastolic function, abdominal aortic thickness and calcification, arterial stiffness, metabolic syndrome, abdominal adipose tissue, and correlation with autonomous cortisol secretion. Furthermore, we discuss modalities to differentiate the types of mutations before surgery. KCNJ5 somatic mutations in patients with APA had higher left ventricular mass (LVM), more impaired diastolic function, thicker aortic wall, lower incidence of metabolic syndrome, and possibly a lower incidence of concurrent autonomous cortisol secretion, but better improvement in LVM, diastolic function, arterial stiffness, and aortic wall thickness after adrenalectomy compared to patients without KCNJ5 mutations.

Characteristics of psychiatric patients with hypokalemia after yokukansan administration: A retrospective study.

Yokukansan is a Japanese herbal medicine used in psychiatry to treat behavioral and psychological symptoms of dementia and other psychiatric symptoms. However, the glycyrrhizic acid included in this medicine can cause pseudoaldosteronism and hypokalemia. We aimed to identify the risk factors for hypokalemia due to yokukansan. A retrospective cohort study was conducted on patients previously treated with yokukansan. The risk factors were determined by comparing the hypokalemia group with the non-hypokalemia group for each parameter. This study included 304 patients who received yokukansan treatment between April 2009 and March 2019. We found that 17.4% (n = 53) of the patients experienced yokukansan-induced hypokalemia. Risk factors detected as significantly different between patients with and without yokukansan-associated hypokalemia were low serum potassium concentration before yokukansan administration, dose 7.5 g /day or more, and dementia. Hypokalemia occurred earlier in patients with low albumin, low potassium, and dementia. It is necessary to pay attention to hypokalemia onset when administering yokukansan at 7.5 g or more to patients with low potassium levels and dementia. Our findings suggest that potassium levels must be checked early after yokukansan administration, especially in patients with low albumin, low potassium, and dementia.

Blood Plasma Minerals and Biochemical Profile of Anestrus and Endometritic Cows Reared in Tribal Areas of Himachal Pradesh, India

Blood samples were collected from 227 infertile (Endometritis; n=123, Anoestrus; n=104) cows from five different tribal locations of Himachal Pradesh viz. Lahaul, Spiti, Kinnaur, Pangi and Bharmour. Significantly, lower levels of potassium were recorded in the Kinnaur district in both anestrus (3.33±0.09mmol/L) and endometritic (3.30±0.12mmol/L) cows as compared to other tribal areas. Significantly, higher levels of AST (p&lt;0.01) were found in anestrus cows of Pangi (103.76±6.07 U/L) followed by Bharmour (93.34±14.43 U/L). The levels of cholesterol were significantly higher in anestrus cows of Lahaul (189.63±16.99 mg/dl) followed by Bharmour (184.54±19.57 mg/dl) and Pangi (162.03±13.83 mg/dl). The levels of creatinine were significantly higher (p&lt;0.05) in anestrus cows of Spiti as compared to other tribal areas. The levels of ALT were significantly higher in anestrus cows of Spiti (37.22±2.01 U/L) followed by Pangi (34.44±3.19 U/L) and Lahaul (29.46±7.35 U/L). In the case of endometritic cows, values of ALT were significantly higher in Spiti (42.41±2.64 U/L) followed by Lahaul (23.37±4.9 U/L). The levels of total protein were found significantly higher in endometritic (8.34±0.31g/dl) cows of Lahaul as compared to other tribal areas.

A study on microbiota isolated from olive mill wastewater disposal ponds, with emphasis on filamentous fungi and their biodegradative potential in North Sinai Governorate, Egypt

The microbial composition of olive mill wastewater (OMWW) from six disposal ponds at three localities in North Sinai Governorate, Egypt has been studied. Such OMWW samples contained a variable (but high) number of bacteria, yeasts, and mold. Eighty-one isolates related to 9 bacterial species were recovered, and seven common bacterial species were isolated from Bir al Abd, Al-Arish, and Rafah sites sources namely Enterococcus faecalis, Escherichia coli, Bacillus cereus, B. subtilis, Micrococcus luteus, Pseudomonas aeruginosa, and Klebsiella pneumonia. In addition to these species, Vibrio cholerae and Shigella species were isolated from the Bir al Abd site. One hundred and twenty isolates related to 13 fungal species were recovered. Seven members of different fungal genera (Aspergillus, Penicillium, Fusarium, Paecilomyces, Alternaria, Chaetomium, and Rhizopus) were recorded. Four genera were widely distributed, and they were able to grow efficiently in undiluted OMWW as a sole source of nutrients. Strains of Aspergillus, Penicillium, Fusarium, and Paecilomyces showed a marked capacity for OMWW detoxification. The physicochemical studies further revealed the presence of relatively low levels of sodium, potassium, calcium, magnesium, and iron. Nitrate concentration was relatively high, 70.13 mg/L. The biological oxygen demand (BOD) and the chemical oxygen demand (COD) recorded high values that ranged between 2210-2270 mg/L and 22760-22800 mg/L, respectively. High BOD and COD values are important indicators of high organic and inorganic components of OMWW and possible negative environmental consequences. The presence of fungal and bacterial species implied possible degradation of the effluent.

Diagnostic value of the fractional excretion of urine potassium for primary aldosteronism.

Primary aldosteronism (PA) is a common form of secondary hypertension, which usually manifests low blood potassium levels. The fractional excretion of urine potassium (FEK) has been proposed as a useful tool to measure urinary potassium excretion. However, the role of the FEK in PA remains unclear. In the current study, we assessed the diagnostic value of FEK in PA. A total of 155 hypertension patients were included in this cross-sectional study, of which 62 were confirmed by a positive screening test for PA. We collected the serum, 24-hr urine samples, and spot urine samples to evaluate the diagnostic value of the spot and 24-hr FEK in the diagnosis of PA and renal potassium loss compared to other indices. The sensitivity and specificity of the related diagnostic indexes were analyzed using receiver operating characteristic (ROC) curves, and the optimal cut-point value of the diagnostic index was determined according to the Youden index (YI) (sensitivity + specificity - 1). Correlation analysis was performed between the spot FEK and 24-hr FEK using Pearson's correlation coefficient. The spot FEK (7.3 vs. 5.9) and 24-hr FEK (9.3 vs. 8.0) levels were statistical differences between the PA and essential hypertension groups. PA patients had a significant tendency to lose potassium through the kidneys. We found that FEK from spot urine distinguished renal potassium loss with a sensitivity of 86.7% and a specificity of 87.1% at a cut-off of 9.8%. The sensitivity and specificity of the spot FEK in screening PA were 51.6% and 76.3%, respectively. FEK is significantly related to renal potassium loss. Spot FEK and 24-hr FEK performed a certain diagnostic value for PA, which may be potential indicators for the differential diagnosis of PA.

PS-R03-9: PERIODIC PARALYSIS AS A PRESENTATION OF PRIMARY HYPERALDOSTERONISM: A CASE REPORT

Objective: the typical clinical presentations of patients with primary aldosteronism (PA) include generalized weakness, fatigue, high blood pressure and potassium deficiency. However, onset of PA with periodic paralysis is rare. Design and method: herein, we present the case of a 40-year-old, Caucasian women (BMI 25,6 kg/m2) with severe resistance arterial hypertension (BP 200–190/110–120 mmHg while taking antihypertensive drugs: valsartan 320 mg/day, bisoprolol 5 mg, hydrochlorthiasid 12,5 mg, amlodipin 10 mg/day, spironolacton 25 mg/day) and muscle weakness. Over the last 2 years prior to presentation, she had multiple such episodes of generalized weakness and losing the ability to stand up, move limbs, wich typically lasted for few minutes to hours/days and resolved spontaneously. Her blood pressure was uncontroled despite taking antihypertensive drugs. She was hospitalized several times because of these conditions, but there is no data on potassium levels during that period. Due to misdiagnosis, she was operated on twice (discectomy C5-C6, C6-C7 and resection of the right internal carotid artery due to pathological tortuosity), but her condition did not improve. Results: At the presentation U waves were registered in the electrocardiography the laboratory examination revealed low plasma potassium level (3,05 mmol/l). Serum TSH, cortisol level were normal. Pasma aldosteron level was 38,6ng/dl (n. 4–31). CT abdomen: adenoma of left adrenal gland. Surgical adrenalectomy was performed. Pathological diagnosis was a bening cortical adenoma. Outcomes: Patient's serum potassium level became normalized after surgical removal of adrenal adenoma. Patient's blood pressue is controlled (130/80 mmHg) by taking a fixed combination perindopril 10 mg/indapamid 2,5 mg/amlodipin 10 mg daily and there is no muscle weakness. Conclusions: Patients with periodic acute muscles weakness and arterial hypertension should monitor electrolyte levels, especially potassium, and evaluate for primary hyperaldosteronism to avoid delayed diagnosis and treatment.

PS-C26-1: USEFUL MARKERS FOR RENAL PROGNOSIS IN HYPERTENSIVE EMERGENCIES WITH SEVERE RENAL DYSFUNCTION

Background: Hypertensive emergencies are poor prognosis conditions associated with rapid blood pressure (BP) elevation and various organ damage. The frequency of dialysis induction due to nephrosclerosis is high and early detection and appropriate therapeutic intervention are important. Methods: We selected 15 patients diagnosed as hypertensive emergencies with severe renal dysfunction (serum creatinine level &gt; 2.5 mg/dL) admitted to our hospital between 2005 and 2019. These were divided into two groups: those who received a renal replacement therapy (RRT) after 3 years and those who were not received (non-RRT). The clinical features and laboratory data between the two groups were reviewed and compared retrospectively. Results: The median age was 48 years old and the male to female ratio was 3:1. All the patients lacked medical examination and regular checkups after diagnosis of hypertension. 33% of them were obese with body mass index &gt; 25. Six patients resulted in end-stage renal disease and received RRT. On admission, about 80% had elevated plasma renin activity and serum aldosterone levels, while there were no cases of renal artery stenosis. Between two groups, there was no significant difference in serum creatinine levels. Serum LDH levels in the non-RRT group were higher than those in the RRT group. Serum potassium levels and platelet counts were lower, respectively. These data at post-antihypertensive treatment was improved significantly in the non-RRT group. Serum values of LDH, potassium, and platelet in the comparison of pre-and post-treatment data of the two groups showed significantly improved by two-way analysis of variance. Discussion and Conclusion: The mechanism of the onset of hypertensive emergencies is still unclear. Severe hypertension causes severe vascular injury and multiple organ damages. In our study, there were young or middle-aged adults and some of them were obese. Therefore, taking health-checkup is helpful for the prevention of the risk of hypertension and appropriate treatment. Higher LDH levels and decreased platelet counts in the non-RRT group suggested the development of severe endothelial damage with rapid BP elevation in the short term. Severe renal dysfunction in these cases can be improved to some extent by appropriate antihypertensive therapy. Furthermore, the lower potassium level suggested the aggravation of the renin-angiotensin-aldosterone system (RAAS) and early induction of RAS inhibitors would be beneficial for the maintenance of BP and renal protection. In conclusion, the value of serum LDH, platelet count, and serum potassium would be predictors of renal prognosis.

Epidemiological and Clinical Investigation of Snake Bite Cases Admitted to the Emergency Department of a Tertiary Hospital in Izmir

Objective: There are more than 3000 snake species in the world, about 30% of which are known to be venomous. Snake poisoning can cause serious mortality and morbidity. In this study, it was aimed to investigate epidemiologically and clinically the snake bite cases admitted to the emergency department of a tertiary hospital in Izmir.&#x0D; Material and Methods: Patients who applied to our emergency department with the complaint of snake bite between 2012 and 2022 were included in the retrospective observational study. The data of the patients were obtained by scanning the hospital electronic database. Vital signs, laboratory values, physical examination findings and outcomes of the patients were evaluated.&#x0D; Results: Of the 52 patients, 22 (42.3%) were female, 30 (57.7%) were male, and the mean age was 48±16. It was seen that the most cases occurred in the summer season and only 1 patient died in total. Snake bite was seen on extremity in 41 (78.8%) patients while 11 (21.2%) had non-extremity bites. There was a statistically significant difference in CK value, potassium value, local edema and diffuse edema incidence between the two groups according to the bite site.&#x0D; Conclusion: Higher CK, lower potassium level and more local and diffuse edema are seen in extremity bites compared to non-extremity bites.

224: ALTERNATIVE MANAGEMENT OF DIABETIC KETOACIDOSIS DUE TO REFRACTORY HYPOKALEMIA

Introduction: In a hypoglycemic state, potassium levels are falsely elevated due to potassium shifting extracellularly. Once insulin is initiated, potassium will reverse, returning intracellularly, and leading to a lower potassium level. It is this reason that the standard protocol of diabetic ketoacidosis (DKA) treatment is to not begin insulin until potassium is replenished above a designated level. Below we present a patient with DKA that required treatment outside of standard protocol due to refractory hypokalemia. Description: The patient is a 25-year-old male that presented to the emergency department (ED) with elevated glucose for the past few weeks. He is a type-2 diabetic, controlled with diet and exercise for the last year. Prior to which, he had been on insulin. The only exacerbating factor he can think of is receiving the J&J vaccine around the same time. Other associated symptoms are difficulty breathing, abdominal pain, mild nausea, but no vomiting. In the ED, he was found to be in DKA with labs significant for severe acidosis and critical hypokalemia of 1.6 mmol/L. A central line was placed and potassium repletion began prior to initiating insulin drip, with plan to start insulin once potassium corrected. Following aggressive potassium repletion with up to 40 mEq per hour, it persistently remained below 3 mmol/L. Thus, it was decided to start the patient on the lowest rate of the insulin drip at 0.02 units/kg/hr until his potassium rose above 3.3 mmol/L as per our protocol. While being on the insulin drip, he was also receiving 20 mEq potassium hourly via IV, 40 mEq orally every four hours, with frequent basic metabolic profiles every two hours. The patient remained on the insulin drip for three days until he was finally able to be transitioned to long-acting insulin, 73-hours after admission. Discussion: The treatment of refractory hypokalemia in the setting of DKA is intricate. Insulin, while imperative for the treatment of DKA, can worsen hypokalemia, therefore sequence of medication administration is important in treatment. It is important for providers to recognize and identify the side effects of these treatments. In this case, multidisciplinary rounds were crucial in both monitoring and replacing potassium while on an insulin drip.

CASE SERIES OF HYPOKALEMIC PERIODIC PARALYSIS

The Periodic paralysis syndrome are described as channelopathies that manifest as abnormal, often potassiumsensitive,muscle-membrane excitability and lead clinically to episodes of accid weakness or paralysis, sometimes in association with abnormalities of the plasma potassium level. Strength is initially normal between attacks, but progressive myopathic weakness may develop in up to one-third of patients. Hypokalemic periodic paralysis characterized by attacks that tend to occur on awakening,after exercise, or after a heavy meal and may last for several days. Patients should avoid excessive exertion. A low-carbohydrate and low-salt diet may help prevent attacks.An ongoing attack may be aborted by potassium chloride given orally or by intravenous drip, provided the ECG can be monitored and kidney function is satisfactory. We report a case series of 3 gentlemen with sudden onset paralysis of extremities and laboratory evaluation revealed a low potassium level. The patient paralysis resolved upon repletion of his low potassium and was discharged with no neurologic decits.

Scoping review: QT interval prolongation in regimen containing bedaquiline and delamanid in patients with drug-resistant tuberculosis.

A regimen containing bedaquiline-delamanid is recommended in management of drug-resistant tuberculosis (DR TB) to increase a success rate. However, this regimen was rare in a clinical setting due to a potential risk of QT prolongation. Several studies have reported the incidence of QT prolongation after administration of this regimen, but the results are inconsistent due to different sample size, study design, and covariate. The aim of this review is to summarize and analyze the published articles related to QT prolongation of bedaquiline and delamanid in PubMed and ScienceDirect databases using a scoping review. This scoping review was conducted under PRISMA for scoping review. The outcomes of this review were incidence of QT prolongation and death. We found 8 articles to be included in this review. The incidence of QT prolongation was higher for DR TB patients who received a regimen containing bedaquiline and delamanid. However, this review found no clinical symptoms, such as cardiac arrhythmias, torsade de pointes, or even death. DR TB patients, especially the elderly, were at risk for QT prolongation. Special consideration in patients with HIV and low level of potassium should be closely monitored for QT interval. The regular measurement of electrocardiography was highly recommended to evaluate QT interval. Generally, the use of individualized regimen containing bedaquiline and delamanid is relatively safe in DR TB patients.

A 21-Year-Old Woman with Suspecting Gitelman Syndrome

&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;Gitelman syndrome (GS), is a hereditary condition marked by a specific kidney function impairment. GS symptoms do not normally manifest until beyond the age of six years. We present a rare case of a 21-year-old woman with a background in generalized weakness muscle cramps with tetany, fever, and dyspnea. The goal of this study is to give a case report of Gitelman syndrome suspicion.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Result:&lt;/strong&gt; Gitelman syndrome is identified through clinical indicators and lab testing, such as low potassium and magnesium levels in the blood, metabolic alkalosis, and low calcium levels in the urine. We do a variety of physical and laboratory tests to determine the disease and rule out other possibilities. Molecular proof is difficult to get due to a lack of resources and the high expense of genetic testing, which has become one of our case report's flaws. This patient was diagnosed as suspecting Gitelman syndrome and treated for electrolyte imbalances. The patients were given replacement therapy, which comprised intravenous potassium, sodium, and chloride therapy, as well as calcium therapy. In addition, we also provided some symptomatic therapy. She was discharged five days later in fine condition.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion :&lt;/strong&gt; This is one of the few reports of a 21-year-old lady being suspected of having Gitelman syndrome (GS). We conduct a battery of physical and laboratory tests to diagnose the disease and rule out other possibilities. We provide the appropriate therapies in accordance with the guidelines, and the outcomes are favorable.&lt;em&gt;&lt;/em&gt;&lt;/p&gt;

A Rare Disorder: Hypokalemia Induced Paralysis

Hypokalemic (Induced) Periodic Paralysis is a rare group of disorders that can cause sudden onset of flaccid paralysis. Here we present a case of 41 year old female who presented to the ED complaining of severe flaccid paralysis in both lower &amp; upper limbs since morning. Initially, she was treated as a stroke alert patient and had head scans which showed no acute pathologic changes. Laboratory evaluation revealed a markedly low potassium level. The patient's paralysis resolved after potassium correction and she was discharged with no neurologic deficits. Although rare, Periodic Paralysis must be differentiated from other causes of weakness and paralysis so that the proper treatment can be initiated quickly.

Increased susceptibility to ventricular arrhythmia at low-normal and moderately low levels of extracellular potassium in catecholaminergic polymorphic ventricular tachycardia.

Recent studies have shown that the predominant arrhythmogenic mechanism in hypokalemia is through inhibition of cardiac Na+/K+ ATPase [Figure 1A(1)]. This results in accumulation of intracellular Na+, which reduces the concentration gradient across the sodium/calcium exchanger [Figure 1A(2)]. The resultant Ca2+ buildup activates CaMKII, an enzyme that facilitates further Na+ and Ca2+ accumulation by activating cardiac ryanodine receptors (RyR2), L-type Ca2+ channels, phospholamban, and the late sodium current [Figure 1A(3)].